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How low literacy can affect your health

March 6, 2008

“By understanding what influences our health, we can take action for ourselves and for our communities” -- Canadian Health Network

Learning about health-related issues allows individuals to gain control over their own health by helping them make educated decisions to improve their health outcomes. Attaining any control over health outcomes requires the ability to find reliable and up-to-date health-related information, the ability to understand that information, and the ability to apply the information to specific life situations. Literacy skills are a critical component in this equation and too many Canadians lack strong health-literacy skills. Despite Canada’s pride in a national health-care program and a relatively high standard of living, disparities in literacy skills have a significant negative impact on the health of Canadians.[1]

According to the Survey of Canadian Attitudes toward Learning (SCAL), Canadians rely on a variety of sources of information to learn about health-related issues.[2] When more than 5,200 Canadians were asked about the sources of health-related information they use, respondents reported using an average of five different sources of health-related information in the past year.

Canadians turn first and foremost to their family physician for health-related information, but they also consult many other sources of information, including media sources such as television, radio and newspapers. They also consult their friends and family members for advice, search books and the Internet, and visit community health-service providers including nurses, nurse practitioners, and (in Quebec) CLSCs (Centre local de services communautaires; See Table 1).

Many of the sources of health-related information that Canadians rely upon require a minimum level of literacy, but many Canadians do not possess sufficiently strong literacy skills. According to Statistics Canada, nearly half (48%) of Canadians aged 16 years and older do not have literacy skills strong enough to cope with the demands of an increasingly knowledge-based society.[3] Poor literacy skills tend to be concentrated among particular groups of Canadians. For example, results of the 2003 International Adult Literacy and Skills Survey indicate that older Canadians and Canadians with lower levels of educational attainment tend to score lower on literacy assessments (see Figure 1 for results on the Prose Literacy scale).

Figure 1: Prose literacy, by age and education level in Canada Source: IALS Survey (2003) Note: Scores 0-225 = Level 1; scores 226-275 = Level 2; scores 276-325 = Level 3; scores 326-375 = Level 4; scores 376-500 = Level 5.

Older and less educated Canadians tend to use fewer sources of health-related information and are less likely to make use of sources of information that require strong literacy skills, such as books, the internet and public libraries.

SCAL respondents with some postsecondary education report using an average of six different sources, whereas those with only a high school diploma report using five sources and those who have not completed high school report using only four different sources of health-related information. It is not surprising that education-related differences are greatest for those sources that require some degree of literacy, such as the Internet, books, and public libraries, although those at the lowest educational levels are also less likely to consult friends and family members (see Figure 2).

Figure 2: Percentage of respondents who report having used each source of information in the past year by level of education Source: SCAL 2006

Younger Canadians tend to use a wider variety of sources of health-related information than older Canadians. On average, respondents aged 20 to 44 years report using six different sources, those aged 45 to 64 years report using five, and respondents 65 years or over report using only four sources of health-related information. In particular, older Canadians are much less likely to use sources of health-related information that rely on literacy skills, such as the Internet, books, and public libraries (see Figure 3).

Figure 3: Percentage of respondents who report having used the Internet, books or the public library in the past year by age group Source: SCAL 2006

Much of the available information about prescriptions, disease prevention and health maintenance is written above the reading ability of many patients. [4], [5], [6], [7] This has clear consequences for health outcomes. SCAL findings indicate that individuals who are at risk for low literacy skills report fewer attempts to learn about health-related issues. In Canada, individuals with lower levels of literacy are more likely to report poor health and suffer from chronic disease. They also report a lack of knowledge about managing their health and tend not to engage in disease prevention behaviour.[8]

Lessons in Learning: How to Address the Problem of Low Health Literacy?

The potential for negative health outcomes associated with low literacy, and particularly with low health literacy, is not restricted to a small portion of the population. According to the Adult Literacy and Life Skills Survey, more than half (60%) of Canadians over the age of 16 do not possess the minimum health literacy skills required to read and understand medication and nutrition labels, give informed consent, or understand safety instructions for equipment and machinery.[9] In all of these cases, inadequate literacy skills can pose significant health and safety risks: improving the health literacy skills of Canadians is therefore a critical issue.

Efforts to improve health literacy must include appropriate educational and support strategies directed toward health professionals. To begin with, the education of health professionals should include information on the high prevalence of inadequate functional health literacy and its relationship to poor health, and to incorporate training on how to be effective in addressing the needs of low-health-literacy patients.[10] As well, health care providers “need to be supported to develop the competencies to provide self-management support and to have options for self-management support available to match the needs of the patients.”[11]

In Canada, work is already underway to address the issue of health literacy among health professionals. For example, the Canadian Public Health Association's (CPHA) National Literacy and Health Program is working in partnership with 27 national health associations to raise awareness among health professionals of the important link between literacy and health. One strategy has been to raise awareness among health professionals that the health information provided by hospitals and clinics is currently difficult to understand for many Canadians. [12] The CPHA encourages health professionals to use clear and plain language in their verbal interactions with patients and on print material.[13] Health professionals can play an important role in ensuring that health information is well understood by using simplified language, stressing key information and making use of lists.[14] They must, however, be given the time and appropriate training to do so.

Additional programs are also being developed by individual jurisdictions in Canada. For example, the Nova Scotia Departments of Health and Education have developed a Health Literacy Awareness Initiative to raise awareness among primary health care providers about literacy issues and how they can help their patients to better understand health information. [15]

Health professionals can make a large contribution toward addressing the issue of health literacy, but consumers of health care must also participate in improving their own health literacy. A program developed in Edmonton, Alberta provides a good example of promising practices for increasing literacy skill among consumers of health-related information. An adult learning centre created a program that specifically links literacy with health. As part of the program, low-income women learn about nutrition, exercise, and strategies for reducing stress. The students and instructors report improvements in participants’ literacy and in their ability to find health information and services. As well, participants have noted positive changes in eating habits and physical activity.[16] Programs such as these have far reaching effects beyond the participants themselves. Once individuals learn appropriate strategies for maintaining personal health, they often share that knowledge with family and friends.

Additional efforts are required to improve health literacy and access to health-related information among all Canadians.

In 2006-2007, the Canadian Council on Learning’s Health & Learning Knowledge Centre facilitated consultations with adults with low literacy both in and out of learning programs, with immigrants and refugees, and with service providers and practitioners across Canada. Although participants reported that the Internet is a good source of health-related information, they also agreed that the volume of information available online is sometimes overwhelming, difficult to understand, and unreliable. These consultations revealed the need for websites that provide health-related information in plain and accessible language.

There is also a need for effective strategies for providing health literacy services to those who most need them. It is recognized that adult basic education (ABE) programs are appropriate places to improve health literacy skills,[17] yet the difficulty lies in helping those individuals with low literacy skills who are not enrolled in ABE programs. Under-reporting of literacy difficulties presents a significant barrier to implementing strategies to improve health literacy: those in need of literacy assistance are often reluctant to reveal their lack of skill.[18]

Health care practitioners also need to develop a deeper awareness of the extent to which low literacy permeates the Canadian population. In addition, it is important to measure any changes in levels of health literacy in the Canadian population in order to document best practices with those changes. A health literacy index could further both of those goals by providing a composite measure of the health competence and capabilities of Canadians at national, provincial, community and key demographic group levels. Such a composite index would be informative to health care practitioners as a measure of population levels of health literacy. It would also be informative to decision makers as a measure of the outcomes of health and health literacy promotion activities.[19]

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information.

Useful Links

ABC CANADA Literacy

Canadian Alliance of Community Health Centre Associations (CACHCA)

Canadian Consortium on Health Promotion Research

Canadian Health Network/Réseau canadien de la santé

Canadian Health Librarian’s Association

Canadian Institute for Health Information

Canadian Public Health Association

• Health Literacy Portal

Centre for Health Promotion

Consortium national de formation en santé

Health Canada/Santé Canada

Health and Learning Knowledge Centre

IDM Best Practices for Health Promotion, Public Health and Population Health

Movement for Canadian Literacy

National Adult Literacy Database

National Collaborating Centre for the Social Determinants of Health

Public Health Agency of Canada/Agence de santé publique du Canada

Women's Health Matters

World Health Organization

References

Learning about health-related issues allows individuals to gain control over their own health by helping them make educated decisions to improve their health outcomes.